Erectile dysfunction (ED) remains one of the most common and challenging complications following radical prostatectomy, significantly affecting quality of life. While nerve-sparing techniques during robot-assisted radical prostatectomy (RARP) aim to preserve erectile function, recovery is often variable. Low-intensity extracorporeal shockwave therapy (Li-ESWT) has gained interest as a non-invasive option for penile rehabilitation, promoting neovascularisation and potential nerve regeneration. This case series reports our early experience using Li-ESWT for ED following RARP at a single Malaysian institution.

Patients who underwent unilateral or bilateral nerve-sparing RARP at our centre were enrolled in the study. Tadalafil 5 mg daily was initiated postoperatively, and patients received Li-ESWT using the Dornier Aries® 2 device. A total of 3,000 shocks per session were delivered over six weeks, with a total of 12 sessions. The use of a vacuum erection device was optional. Patients were followed up for 12 months. Baseline erectile function was assessed using the International Index of Erectile Function-5 (IIEF-5), Erection Hardness Score (EHS), and stretched penile length (SPL). Follow-up assessments were conducted at 1, 6, and 12 months post-RARP to evaluate changes in IIEF-5, EHS, and SPL.

From January 2023 to January 2024, six patients with persistent ED after nerve-sparing RARP were enrolled. The mean (SD) age was 66.2 (8.2) years, with a mean (SD) preoperative PSA of 10.12 (8.9) ng/mL. The median preoperative IIEF-5 score was 22 (range: 17–24), and the median EHS was 3.5 (range: 3–4). At one month postoperatively, none of the patients had resumed sexual activity, and EHS ranged from 1 to 2. At 6 and 12 months, limited improvement in IIEF-5 and EHS was observed. Notably, only patients who had bilateral nerve-sparing procedures reported some degree of erectile function recovery. There were no notable changes in SPL across follow-up intervals. Li-ESWT was well tolerated, with no adverse effects reported.

Li-ESWT appears to be a safe and feasible option for managing ED following RARP. However, in this small cohort, functional improvement was limited, particularly in patients who had undergone unilateral nerve-sparing surgery. It is important to note that the recovery of erectile function post-RARP is influenced by multiple confounding factors, including patient age, baseline function, nerve-sparing status, and adherence to rehabilitation. Further studies with larger sample sizes and longer follow-up are warranted to better evaluate the role of Li-ESWT in post-prostatectomy penile rehabilitation.